Table Of Content

C h THE PAIN CENTER MANUAL a n g P | H A I N a T Danielle Perret, MD ta | CPerr H E he Eric Chang, MD | Justin Hata, MD ent Hamilton Chen, MD | Bianca Tribuzio, DO | Tr ib u z io C The Pain Center Manual is a concise resource that provides practical information E N T E R for daily use in pain practice. For quick reference or on-the-spot guidance in T academic or community pain centers, these pages are ﬁ lled with the informa- H tion trainees and experienced practitioners need at their ﬁ ngertips including common medication dosages, titration schedules, dictation templates, assess- E ment scales, guidelines for interventional procedures, and much more. P A team of experts from one of the country’s leading university pain centers A M cover everyday management concerns such as methadone safety, prescription A N UA L writing for controlled substances, neuropathic medication adjuvants to con- I N sider in pain management, and treatment suggestions for a wide spectrum of chronic pain conditions. With an emphasis on ACGME standards and objec- C tives, the manual offers the fundamental knowledge pain professionals need to provide consistent and compassionate care. E N The Pain Center Manual includes: T • Quick reference tables for medications and other treatment modalities E • Clinical pearls for the most common pain complaints R • Templates for consultations and interventional procedures • Useful scales, algorithms, diagrams, and other essential reference M materials for performing tests and procedures • ACGME training guidelines A N Danielle Perret U Recommended Shelving Category: Physical Medicine & Rehabilitation / Neurology/Anesthesia A Eric Chang | Justin Hata ISBN 978-1-620700-21-1 L Hamilton Chen | Bianca Tribuzio 11 W. 42nd Street New York, NY 10036-8002 9 781620 700211 www.demosmedpub.com The Pain Center Manual The Pain Center Manual Danielle Perret, MD Assistant Dean for Resident Affairs Director, Fellowship Program in Pain Medicine Associate Director, Residency Training Program in Physical Medicine and Rehabilitation Associate Clinical Professor Department of Anesthesiology and Perioperative Care Department of Physical Medicine and Rehabilitation UCI Center for Pain Management University of California-Irvine Eric Chang, MD Assistant Professor In-Residence Division of Pain Medicine Department of Anesthesiology and Perioperative Care Department of Physical Medicine and Rehabilitation Department of Orthopedics Reeve-Irvine Research Center for Spinal Cord Injury University of California-Irvine Justin Hata, MD Chief, Division of Pain Medicine Director, Residency Training P rogram in Physical Medicine and Rehabilitation Associate Clinical Professor Department of Anesthesiology and Perioperative Care Department of Physical Medicine and Rehabilitation Medical Director UCI Center for Pain Management University of California-Irvine Hamilton Chen, MD Pain Medicine Fellow Department of Anesthesiology and Perioperative Care UCI Center for Pain Management University of California-Irvine Bianca Tribuzio, DO Pain Medicine Fellow Department of Physical Medicine and Rehabilitation UCLA/West Los Angeles-VA New York Visit our website at www.demosmedpub.com ISBN: 9781620700211 e-book ISBN: 9781617051845 Acquisitions Editor: Beth Barry Compositor: Exeter Premedia Services Private Ltd. © 2014 Demos Medical Publishing, LLC. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Medicine is an ever-changing science. Research and clinical experience are continually expanding our knowledge, in particular our understanding of proper treatment and drug therapy. The authors, editors, and publisher have made every effort to ensure that all information in this book is in accordance with the state of knowledge at the time of production of the book. Nevertheless, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the contents of the publication. Every reader should examine carefully the package inserts accompanying each drug and should carefully check whether the dosage schedules mentioned therein or the contraindications stated by the manufacturer differ from the statements made in this book. Such examination is particularly important with drugs that are either rarely used or have been newly released on the market. Library of Congress Cataloging-in-Publication Data Perret, Danielle, author. The pain center manual / Danielle Perret, Eric Chang, Justin Hata, Hamilton Chen, Bianca Tribuzio p. ; cm. Includes bibliographical references. ISBN 978-1-62070-021-1—ISBN 978-1-61705-184-5 (e-book) I. Chang, Eric, author. II. Hata, Justin, author. III. Chen, Hamilton, author. IV. Tribuzio, Bianca, author. V. Title. [DNLM: 1. Pain Management—Handbooks. 2. Pain—drug therapy—Handbooks. 3. Pain Measurement—Handbooks. WL 39] RB127 616′.0472—dc23 2013033816 Special discounts on bulk quantities of Demos Medical Publishing books are a vailable to corporations, professional associations, pharmaceutical c ompanies, health care organizations, and other qualifying groups. For details, please c ontact: Special Sales Department Demos Medical Publishing, LLC 11 West 42nd Street, 15th Floor New York, NY 10036 Phone: 800-532-8663 or 212-683-0072 Fax: 212-941-7842 E-mail: [email protected] Printed in the United States of America by Gasch Printing. 13 14 15 16 17 / 5 4 3 2 1 Contents Preface ix I. MEDICAL MANAGEMENT OF CHRONIC PAIN 1 Opioids 1 Signs of Opioid Withdrawal 2 Opioid Overnarcotization 2 Notes on Opioid Abuse 2 Opioid Withdrawal Protocol 3 Opioid Screening Tools: SOAPP® Version 1.0–14Q 7 Narcotic Conversions 9 Methadone 10 Safety Considerations 10 Prescribing Methadone 11 Methadone Risk Factors 12 P450 Inhibitors 13 QT Prolonging Drugs 14 Urine Drug Toxicity (UDT) Screens 15 Interpretation of Urine Toxicity Results 15 Types of UDT 17 Controlled Substance Rx Writing Skills 19 Common Medications Used in Pain Management 21 Suggested Outpatient Medication Prescriptions 24 Sample Titration Schedules 29 Metabolic Considerations for Medications 31 Medication Safety in Renal Failure, Pregnancy, Geriatrics 33 Interventional Pharmacology 35 2010 ASRA Recommendations for Anticoagulation in Pain Medicine Procedures 37 Emergency Pharmacology 39 Intrathecal Pump 40 Systemic Effects of Local Anesthetics 43 Traditional Neurolytic Spinal Blocks 45 Botox Injections for Migraine 46 II. DIAGNOSTIC PEARLS FOR PAIN MANAGEMENT 51 How to Present Pain 51 Headaches 52 Cranial Nerve Notes and Pain Boards Association 56 Facial Pain Neuralgias 60 v vi Contents Pelvic Pain Neuralgias 62 Gynecologic Conditions That May Cause or Exacerbate Chronic Pelvic Pain by Level of Evidence 63 Nongynecologic Conditions That May Cause or Exacerbate Chronic Pelvic Pain by Level of Evidence 64 Radiology Pearls 65 Disc Pathology Pearls 66 Spinal Pain Differential 67 Complex Regional Pain Syndrome (CRPS) Pearls 68 Treatment Considerations for Common Pain Presentations 69 III. NOTES AND TEMPLATES 75 Initial Consultation Template 75 Follow-Up Visit Template 80 Interventional Procedure Templates 84 IV. BILLING AND CODING 141 New Patient Billing and Coding 141 Follow-Up Patient Billing and Coding 142 V. SCALES AND OTHER REFERENCE MATERIALS 143 Regional Landmarks 143 Vertebral Levels 144 Brachial Plexus 145 Lumbosacral Plexus 147 Upper Extremity Innervations 152 Lower Extremity Innervations 153 PM&R/Neurology Exam Guide 154 Dermatomes 155 Physical Exam Tests and Acronyms 156 Therapy Contraindications 157 P&O Reference 158 Research Critical Appraisal Questions 159 Sample Procedure Log Form 161 Sample Patient Safety Log 162 Pain Scale Reference 163 Resources 164 VI. ADULT LEARNING IN PAIN MEDICINE 165 ACGME Training Standards 165 ACGME Fellowship Requirements 165 ACGME Fellowship Procedure Requirements 166 ACGME Core Competencies 167 Contents vii Sample Reading Assignments 171 Other Suggested Reading Materials 173 Goals and Objectives 174 Residents 174 Fellows 179 Subspecialty Goals and Objectives 181 Suggested Formal Fellow Evaluation Systems 185 Sample Pain Medicine Curriculum 186 Suggested Didactics Program 187 Cognitive Objectives 191 References 201 Index 203 Preface Welcome to Pain Medicine done right. Patients in pain expect excep- tionally qualified and compassionate care. Determining the appropriate approach for each patient is a nuanced art, but a solid grasp on the base knowledge can put this goal within reach. This concise handbook is your continuous guide to the best practices reflective of academic pain management. It’s not an encyclopedia, but it is full of pearls of knowledge for quick reference and on-the-spot training in both academic and community-based medicine. For the medical student or resident rotating through Pain, fellow in training, academic faculty, or private attending, this manual is your guide to our best practices. In these pages, you’ll find common medication dosages, procedure templates, pharmacotherapies, and other useful diagnostic and treatment strategies, all reflective of interdisciplinary multimodal Pain Medicine techniques we use in the University of California chronic pain clinic and procedure suites. You’ll also find a guide to the Accreditation Council for Graduate Medical Education (ACGME) standards, objectives, and suggested readings. Where large textbooks fail to offer practical guidelines for everyday pain management, this resource fills in the gaps. This is the manual we rely on, every day, because it works. We hope it becomes a trusted resource for you as well. Danielle Perret, MD Assistant Dean for Resident Affairs Director, Fellowship Program in Pain Medicine Associate Director, Residency Training Program in Physical Medicine and Rehabilitation Associate Clinical Professor Department of Anesthesiology and Perioperative Care Department of Physical Medicine and Rehabilitation UCI Center for Pain Management University of California-Irvine ix